Colorado Do Not Resuscitate Order
This document serves as a direction under the laws of the State of Colorado, specifically referencing the Colorado Medical Orders for Scope of Treatment (MOST) laws, indicating the individual named herein refuses any forms of resuscitation attempts in the event of cardiac or respiratory arrest.
Patient Information
Patient's Full Name: _________________________
Date of Birth: _________________________
Gender: _________________________
Address: _________________________
City, State, Zip: Colorado, ________________
Medical Practitioner's Information
Practitioner's Full Name: _________________________
Qualification: _________________________
License Number: _________________________
Address: _________________________
City, State, Zip: Colorado, ________________
Do Not Resuscitate (DNR) Order
I, _________________________, being of sound mind and understanding the implications, hereby refuse any form of resuscitation including CPR (Cardiopulmonary Resuscitation), advanced cardiac life support, and other life-sustaining interventions in the event I experience cardiac or respiratory arrest, under Colorado law.
This directive is made voluntarily and without any undue influence, understanding fully the consequences of such a decision.
Signature
Patient's Signature: _________________________ Date: ___________________
Witness Signature: _________________________ Date: ___________________
Medical Practitioner's Signature: _________________________ Date: ___________________
Important Information
- This Do Not Resuscitate Order must be reviewed periodically and may be revoked at any time by the patient or their legally authorized representative.
- A copy of this order should be provided to and discussed with the patient's health care proxy, family, or others who may be involved in the patient’s health care decisions.
- This document does not replace the need for other forms of medical treatment that may be beneficial to the patient's wellbeing and comfort.
- This order is only valid within the State of Colorado.